In his August 21 column, Middlebury’s outgoing State Representative Paul Ralston raises some questions about the state’s roadmap to single payer. However, his conclusions are based on assumptions that need more probing. Here are a few of the issues raised that need more careful examination:

1. The column asserts that the state has performed poorly in its “first attempt at health care reform” and that therefore people must now be cautious. However, it is important to make clear that the health care exchanges were federally mandated and not a state idea. Furthermore, single payer is a simpler concept than the health care exchange, as it does not involve different levels of coverage for different people, changing subsidies as your life situation changes, restricted enrollment periods that can leave you in the lurch, and all the rest of the exchange complexity, including a long and less than dependable application process. Rather, with single payer we are all enrolled automatically by virtue of our Vermont residence, and then our coverage is guaranteed. As Act 48 states, Green Mountain Care will cover all Vermonters regardless of any other coverage they may also hold (such as Medicare for which it will act as a wraparound).

2. As stated above, single payer detaches payment from coverage. We are covered regardless of whether we lose a job, get a job, get a divorce, or undergo any other change in our life circumstance, so long as we are a Vermont resident. As far as payment, we have figured out how to pay for other state services equitably, and we can do so for single payer as well.

3. The column states that the program for Green Mountain Care, the proposed single payer plan has no “clear definition.” That is incorrect. Act 48 specifies the minimum cost sharing and coverage for Green Mountain Care, the state’s future single payer plan. The benefit package, by law, must include primary and specialty care, mental health and substance abuse, hospitals and prescription drugs. Under Green Mountain Care everyone will be eligible for these broad benefits, and out of pockets must be kept to a minimum because the “actuarial value,” or the amount that the plan pays, must be kept high. What is still undecided are the categories of adult dental and vision, and this is something on which citizens will need to weigh in about as the legislature considers the financing package in the next session.

4. So, what about the financing parameters? In fact, we already know them. Every professional study has estimated a cost of between $1.6 billion and $2.1 billion for the tax package to fund single payer. That is less than Vermonters already pay in private premiums and out of pockets ($2.6 billion in 2012), and most importantly, it will replace them. Of course, how the tax package is crafted, how progressive it is, what portion will be payroll and what portion income, etc. are important questions. They will be carefully thought about and debated once the administration presents its proposal, the legislature considers and weighs it, and revisions are suggested based on citizen input.

5. Of course, as Ralston’s column indicates, voters do not want their representatives to act like “lemmings” marching into the sea. We expect them to consider carefully how to craft a single payer health care tax package (which will replace premiums) that is as comprehensive and equitable as possible. But, since Act 48 has been passed and is the law, we should insist that our legislators complete the roadmap it laid out. If anything, the problems with the Exchange demonstrates how complicated things get when health care remains tethered to the private insurance system.

To insure seamless coverage for all Vermonters we will need the guaranteed inclusion that is part of a universal publicly financed health care system. That is the goal of the roadmap laid out in Act 48.

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